It’s our duty as physicians to avoid needless tests

I recently presented Yale Surgical Grand Rounds focused on “Cost and Quality in Cancer Care.” Amidst the talks in Washington regarding our unsustainable health care spending, and provisions of the Affordable Care Act rapidly taking hold, it seemed appropriate to start to critically evaluate how we spend our health care dollar and the value we receive in return. The data are not news to anyone. We spend more per capita than any other nation on earth, and yet the Organization for Economic Cooperation and Development (OECD) and the Commonwealth Fund find the U.S. lagging in terms of access, quality, efficiency, and equity of care. How can this be? We spend more than twice the OECD average on MRIs and CT scans, and our unabashed (and sometimes inappropriate) use of these may drive up costs without a commensurate improvement in quality despite innovations in technology.

I told the story of a very elderly patient of mine, who had gone for a routine screening mammogram, which found a speck of calcifications which were further evaluated with magnification views and a biopsy before she was referred to me with low grade DCIS for surgical considerations. We had a very frank discussion – although she was certainly healthy for her very advanced age, with hypertension as her only comorbidity, one had to wonder about the natural history of her disease and whether this would ever progress to invasive disease that would threaten her quality or quantity of life. As she contemplated whether or not to pursue surgical extirpation of her disease given our conversation, I considered why she had a screening mammogram her age, with little to no evidence of the efficacy of mammography in this population. A recent New England Journal of Medicine article noted significant overdiagnosis, and the paper published in JAMA Internal Medicine estimated annual screening related expenditures associated with mammography in the population over the age of 75 to be $410.6M.

But it’s not just the fact that our duty as citizens should force us to be good stewards of health care resources. It’s our duty as physicians to avoid needless tests that could add to potential morbidity. Beyond that, one cannot underestimate the effect of the financial impact cancer treatment on the quality of life of our patients. Bankruptcy levels continue to rise in this nation, and the #1 cause (accounting for 42% of all bankruptcies) is medical expenses — that’s more than job loss, credit card debt, avoiding foreclosure, preventing loss of utilities, student loans, and car payments combined.

We need to stop the madness –- stop ordering metastatic work-ups on patients with early stage breast cancer; stop doing routine MRIs even on patients planning to have bilateral mastectomies; stop doing a CBC and complete metabolic profile on every patient who walks into your office “just because”….we need to practice more rational evidence-based medicine; and our professional organizations like ASCO need to support these choices with guidelines like its “Top Five.” Soon after I gave the talk, a few people showed me the Time article that came out the same day. The same song, with a different verse. We can no longer choose to ignore the issue, for if we don’t step up to stop the madness, others will stop it for us.

Anees Chagpar is an oncologist who blogs at ASCO Connection, where this article originally appeared.

It’s our duty as physicians to avoid needless tests 11 comments

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Sean

That sounds great I’m sure most of our patients and the country as a whole will appreciate the savings. However being more conservative with our ordering practices will by definition lead to more “missed”diagnoses. Until we have serious malpractice reform in this country there is little incentive to order fewer studies. I’ve been a radiology resident for 33 months and I have already been named in 2 lawsuits. (Neither of which had anything to do with my performance.) I don’t understand why the people who have dedicated their careers to taking care of the health of this country should be expected to take on all the added risk while simultaneously seeing our reimbursement slashed year after year in an effort to save everyone else money. And I don’t want to hear about how overpaid we are as compared to other countries. If you want to start subsidizing medical school with taxes (like every other major industrialized country) then we can talk.

trinu

Malpractice reform needs to be done correctly, the commonly proposed caps on damages have too much of an impact on people with legitimate claims.

bill10526

Almost nobody has a legitimate claim. Lawyers can conger up explanations for adverse outcomes that are actuarial in nature. Americans as a people just can’t understand this simple principle.

One need only ask himself why would a doctor want to harm his patients.

trinu

Even a careless mistake can result in a legitimate claim. Things like wrong site surgery and other never events may be rare, but they’re common enough that the legal system needs to be able to address them.

As for your comment about intent to harm, of course most cases don’t arise from intent to harm. If they did, they would be going through the criminal rather than civil system.

bill10526

You illustrate my point.

Take airplane safety for example. Manufacturers knew early on that the public would not fly in airplanes that had even a non-negligible chance of crashing, and they engineered their products accordingly. Litigation and the FAA contributed nothing to safety. Litigation did come close to shutting down the small-plane market.

The focus on the extremely small chance of an unjust execution has made capital cases horrifically expensive to prosecute; so expensive that Mario Cuomo used the costs to prosecute as an argument to eliminate capital punishment.entirely.

trinu

So now you’ve apparently gone beyond just opposing frivolous lawsuits and believe for instance that if a urologist removes the wrong testicle from a testicular cancer patient, which happened recently in the UK, that there shouldn’t be major consequences.

bill10526

Yes.

trinu

You asked me why a doctor would want to harm his patients. After conversing with you, I am certain you, unlike most doctors, are completely indifferent when it comes to harming your patients. If you want to screw people over and get away with it, I suggest you go back to school and become an investment banker.

bill10526

But you want to exploit the emotional reaction to an unfortunate mishap in surgery for testicular cancer to transfer great sums from medical providers to a greedy patient and his greedy lawyer. Malpractice litigation is a lucrative business and more obnoxious than investment banking.

I am not a doctor myself, but I want doctors to be able to carry out their duties without the worry of unjust lawsuits. Too often doctors were pointed to for causing defects in babies by charlatans miss-reading traces from fetal monitor machines for example.

trinu

You specifically said you didn’t just care about unjust lawsuits; you also didn’t want the urologist in the very legitimate case i mentioned, to pay major damages. I agree about frivolous lawsuits, and maybe we should limit who can serve on malpractice juries.

morebuzzkills

Dr. Chagpar, I completely agree with you that we are on an unsustainable course with regard to health care spending. The statement that physicians must stop the madness of health care spending, however, is somewhat shortsighted. While physicians are certainly in the position to help reduce health care spending by reducing the amount of shotgun testing, this neglects to take into consideration the manner in which many physicians make money. Like it or not, the vast majority of physicians are paid “by the bolt.” Thus the more procedures/tests/studies they order, the higher their income (in most cases). Unfortunately, the social contract associated with being a physician obscures the basic fact that many physicians make their money per activity (whether it is a biopsy, test, imaging study, etc). Let’s think about this idea from an alternative perspective: hair stylists and barbers are paid per styling or haircut. One day the owner (or cosmetology board) comes in and says, “We must reduce the number of haircuts and hair colorings we are performing because it is just getting too expensive. However, you will still be compensated by the number of haircuts and stylings you perform.” Do you think that the collective group of stylists and barbers will reduce the number of “procedures” they perform? Some individuals within the profession might, but the group will unfortunately not reduce their rate of because that is how they are making their money! Let’s take this a step further, imagine now that the cosmetology board decides that all hair care professionals will be paid based off of customer satisfaction. Do you think they will reduce the number of haircuts they perform? You bet. But not so fast, could there be such a reduction in the number of haircuts that such that access to hair care becomes a scarce commodity? It’s possible, especially if hair care professionals perceive the satisfaction metrics as unreasonable or too stringent. Furthermore, is there a degree of perception involved in the evaluation of a good haircut or style? Probably so. Are customers truly equipped to evaluate the quality of a hair styling? The point of this little anecdote is to highlight the fact that it is incredibly easy to blame physicians for ordering excessive testing and health care costs…but are physicians acting all that different from other professions in similar situations? Does your auto mechanic always wait until the optimal time to tell you that your car needs new tires? Maybe…but I’d bet your car might need a new set of tires more often than not if you consistently took it in every year around Christmas. The bottom line is that physicians are human beings and will collectively behave as rationally self-interested creatures. If we wish to change the “by the bolt” behavior of physicians, we must change the way physicians are paid. There is, as I have pointed out, a big caveat to this statement. Many of the knee-jerk quality of care models neglect the issue of physician supply and access to health care services. Going forward, we must realize that the issue of health care costs is rooted in economics and is much more complex that the headlines would have you believe. As a profession, physicians must not fall into the trap of simplicity when it comes to health care costs. Addressing health care spending, just like the delivery of health care itself, must become a team effort. As the other commenters on this piece have pointed out, it’s not just physicians who are at fault. They are merely responding (in a very predictable manner) to the incentives that exist within the profession.